Background: Unfavorable conditions at the soft tissues adjacent to a recession defect may preclude performing pedicle flaps (advanced or rotational) both as a root coverage procedure, and as a covering flap for a connective tissue graft. Free gingival grafts may not be recommended because of the low root coverage predictability and the poor esthetic outcome. The goal of the present case report is to suggest modifications of the two-stage surgical technique aimed at improving root coverage and esthetic outcomes, and reducing patient morbidity.
Method: In the first case report, a Miller class II gingival recession, associated with a deep buccal probing depth, affecting a lower central incisor was treated. In the first step of the surgery an epithelized graft with an apical-coronal dimension equal to the keratinized tissue height of the adjacent teeth was sutured apical to the bone dehiscence. Four months later, a coronally advanced flap was performed to cover the root exposure. In the second case report, a Miller class III gingival recession, complicated with a deep buccal probing depth affecting the mesial root of the first lower molar was treated. In the first step of the surgery, a free gingival graft was positioned mesially to the root exposure to create keratinized tissue lateral to the recession defect. This was adequate to perform the laterally moved, coronally advanced flap that was used as a second-step root coverage surgical procedure.
Results: In the first case report complete root coverage, an increase (4 mm) in keratinized tissue height and realignment of the mucogingival line were achieved 1 year after the surgery. The reduced dimension of the graft permitted to minimize patients discomfort and to obtain good esthetics of mucogingival tissues. These successful outcomes were well maintained for 5 years. In the second case report successful root coverage, increase (3 mm) in keratinized tissue height and good harmony of mucogingival tissues were achieved 1 year after the surgery. These outcomes were well maintained 5 years after the surgery.
Conclusions: The present study suggested that modifications of the two-stage procedure by minimizing the dimension of the graft and by standardizing the surgical techniques allowed successful results to be achieved in the treatment of gingival recessions characterized by local conditions that otherwise preclude the use of one-step root coverage surgical techniques.